Clinical Quality Manager
3 weeks ago
**General Summary of Position**
The Clinical Quality Manager position reports directly to the Director of Quality Resources and will be mentored by more senior staff as needed. Leads and/or facilitates patient safety and quality improvement projects in accordance with the annual Quality and Safety Plan. Provides support and guidance to organizational leaders and clinicians in accordance with the Clinical Performance Improvement Peer Review Program of the Medical and Dental Staff. Facilitates and/or promotes organizational regulatory compliance according to the requirements of The Joint Commission (TJC), District of Columbia Department of Health (DCDOH) licensure and Centers for Medicare and Medicaid (CMS).
**Primary Duties and Responsibilities**
- Leads and/or facilitates patient safety and quality improvement projects - Quality and Safety Council (QSC): A) Works in collaboration with the VP, Quality, Safety and Risk to direct the priorities of QSC. B) Responsible for guiding departments and teams on reporting requirements of the QSC. C) Coordinates and plans monthly meeting priorities and assures reports and follow-up action items are assigned.
- Leads and/or facilitates patient safety and quality improvement projects - Interdisciplinary process improvement teams: A) Teaches and coaches clinical and organizational leaders to direct and manage PI teams using quality methods and tools. (Plan, Do Study, Act (PDSA), Root Cause Analysis (RCA), Failure Modes and Effects Analysis (FMEA). B) Participates in Safety Event Reviews and subsequent action planning teams. C) Serves as internal consultant / facilitator to groups / Interdisciplinary Process Improvement Teams working on quality initiatives, providing guidance and support to plan, implement, and coordinate clinical improvement projects. D) Analyzes process and clinical outcomes data and benchmarks results with comparable organizations. E) Researches and applies evidence-based and best practice models to guide project planning and implementation of interventions. F). Evaluates the work groups output and outcomes and provides feedback to the teams on their performance.
- Leads and/or facilitates patient safety and quality improvement projects - Patient Safety: A) Participates in the ongoing coaching of associates related to the culture of safety and reporting of patient safety events. B) Participates in the oversight of PSEMS modules with subsequent recategorization and/or re-routing to appropriate leadership for mitigation and follow-up. C) Through ongoing monitoring, collection and evaluation of data recommends and facilitates implementation of actions to improve quality and patient safety.
- Provides management support and guidance to clinical and organizational leaders in accordance with Clinical Performance Improvement Peer Review Program of the Medical and Dental Staff: A) Assists clinical department and section chairs in the development and implementation of comprehensive clinical and performance improvement peer review programs that are data driven and evidenced based.
- Provides management support and guidance to clinical and organizational leaders in accordance with Clinical Performance Improvement Peer Review Program of the Medical and Dental Staff: B) Responsible for maintaining the integrity and flow of confidential information that is used for peer review, focus professional practice evaluation (focus review), ongoing professional practice evaluation (OPPE) and reappointments for clinical departments.
- Provides management support and guidance to clinical and organizational leaders in accordance with Clinical Performance Improvement Peer Review Program of the Medical and Dental Staff: C) Aggregates and analyzes data from clinical and organizational databases for the purpose of clinical improvement, quality improvement and patient safety and to support the peer review process.
- Facilitates and/or promotes organizational regulatory readiness and compliance according to the requirements of The Joint Commission (TJC), District of Columbia Department of Health (DCDOH) licensure and Centers for Medicare and Medicaid (CMS): A) Facilitates actual and mock licensure and accreditation surveys.
- Facilitates and/or promotes organizational regulatory readiness and compliance according to the requirements of The Joint Commission (TJC), District of Columbia Department of Health (DCDOH) licensure and Centers for Medicare and Medicaid (CMS): B) Provides quality improvement education to new associate orientation as required to comply with regulatory requirements.
- Facilitates and/or promotes organizational regulatory readiness and compliance according to the requirements of The Joint Commission (TJC), District of Columbia Department of Health (DCDOH) licensure and Centers for Medicare and Medicaid (CMS): C) Maintains current knowledge of standards, rules and regulations as mandated by TJC, DOH, CMS and other quality organizations.
**Minimum Qualifications**
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